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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803929
Report Date: 08/01/2022
Date Signed: 09/07/2022 11:47:29 AM


Document Has Been Signed on 09/07/2022 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:MAGGIE'S CARE HOMEFACILITY NUMBER:
496803929
ADMINISTRATOR:GARCIA, HEHERSON MFACILITY TYPE:
740
ADDRESS:916 RENEE COURTTELEPHONE:
(707) 293-9833
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 6DATE:
08/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Heherson Garcia (Licensee)TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee, Heherson Garcia.

LPA arrived at the facility did had their temperature checked and logged into a sign-in sheet. LPA observed that facility have a poster on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/Licensee conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene and paper products. Commonly touched surfaces are disinfected at least twice a day. Each resident has their own room except two room that are shared by two residents in each room, but facility has the option to take one of the residents to a sister facility in case that needs to isolate and the facility is able to serve meals and deliver medications. LPA/Licensee reviewed their facility sketch and this facility doesn't have another room that can be shared because it will be a fire clearance violation. However, Licensee ensured LPA that they will have to relocate the negative residents to a sister facility. All staff have been trained on PPE protocols and N-95 fit tested. Staff and residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate and received boosters for staff and residents. LPA confirmed that facility is conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. Residents receive indoor visitation with their families and facility is able to perform antigen tests to visitors as well as screening, documenting for symptoms and tracking purposes. Facility has submitted their Covid Mitigation Plan and approved on 1/21/21. The facility also has submitted their Infection Control Plan to CCL for review. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields, hand sanitizer and PPE supplies are accessible for staff.

Licensee will provide updates of the following by 8/8/22: Liability insurance and Emergency Disaster Plan (LIC610E). No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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